POLICY

I. PURPOSE: Process to determine if client meets FirstCarolinaCare Insurance Company (FCCIC) coverage criteria.

II. PROCEDURE: Qualifying Application Criteria

• Business must reside in our service area
• Business must be in operation for at least one year
• Minimum Participation (Required Employee Enrollment)
  • 90 percent for less than 15 “Net Eligible” Employees
  • 85+ percent for 15 to 24 “Net Eligible” Employees
  • 75+ percent for 25 to 50 “Net Eligible” Employees
  • 50 percent for groups larger than 50 “Net Eligible” Employees
• Net Eligible Employees = total full-time employees less full-time employees covered under other qualifying coverage (i.e. Spouse, Medicaid, Medicare, etc.)
• Completed Medical History Questionnaires are required for each requesting employee in the following circumstances: FCC Network - 14 or fewer employees applying for coverage) / PPO network - required for employees when 25 or fewer applying for coverage)
• Employer must contribute at least 50% of the employee single premium
• Employees must be regularly scheduled to work at minimum of 30 hours per week
• Benefits must be offered to all employees (30 hours or more per week)
• All enrollees must be bona fide employees of the company or eligible dependents of such employees as defined in the Certificate of Coverage
• Employer group must submit ESC Quarterly Wage and Tax statements upon application and as requested thereafter
• Employer is responsible for making the payroll deductions for each employee
• Each eligible employee must complete required forms
• The effective date for new group coverage is on the first of the month.
• Premiums are due by the tenth of each covered month.
• Group must agree to sign the Master Group Contract
• Copy of current carrier’s coverage, which lists the covered employees, must be included with Employer Application to determine pre-existing condition limitation
• If enrolling employee has different last name than dependents, proof must be submitted to verify relationship
• The maximum waiting period for eligibility is 90 days
• Employees who waive coverage because they are covered under another employer-based plan, or ERISA self-employed plan, will not be included in the eligible employee count. Copy of ID card or waiver form is required.
• No more than 10% of total eligible may be on COBRA or other self-pay status
• Dual plan options available only with prior approval by carrier
• Carrier must approve any self-funding of the deductible prior to the release of final rates
• All net eligible employees must, if requested, complete our Medical History Questionnaire for Medical Underwriting